Sunday, November 30, 2014

Q:52 year old
male is in refractory hypoxemia due to ARDS. Patient is not an ECMO candidate
due to very recent neuro bleed. Pt. didn't respond to prone positioning
either. In last 24 hours pulmonary artery catheter reading is showing
progressive increase in pulmonary pressure. you requested iNO (inhaled nitric
oxide). RT (Respiratory
Therapy) service informed you that no iNO machine is available. What could be
your alternative?

Answer: Inhaled aerosolized
prostacyclin

Inhaled aerosolized prostacyclin (iAP), is an
effective alternative to inhaled nitric oxide (iNO) for refractory hypoxemia and
severe pulmonary hypertension. Tradiotionally, iNO is used in patients with pulmonary
hypertension and acute respiratory distress syndrome (ARDS), but both iNO and
iAP have been shown to reduce pulmonary vascular pressure and improve
oxygenation in patients with ARDS. Moreover, it is more cost-effective
also.Reference:

Friday, November 28, 2014

Q:What is pulsatile
hepatomegaly?

Answer:In pulsatile hepatomegaly, the pulsations can be felt
clinically over liver area. They can also be confirmed by external hepatic
recordings. These pulsations conformed almost identically to the jugular venous
pulsations in the neck. This is one of the classic sign seen in constrictive
pericarditis. They should disappear after surgical treatment of constrictive
pericarditis. Persistence of the hepatic pulsations after
treatment signifies failure of surgical treatment.

Tuesday, November 25, 2014

Q: 48
year old male is going for coronary stents placement after non-ST MI. Patient
has previous history of severe GERD which is responsive only to
Omeprazole (proton-pumo inhibitor). Which anti-platelet would be
recommended?

Answer:Prasugrel

Clopidogrel (plavix) is the most
commonly used anti-platelet agent along with aspirin in patients requiring
coronary stents. But, clopidogrel has shown to have decreased effect in patients
using proton pump inhibitors (PPI) particularly omeprazole or esomeprazole
(pantoprazole appears to be relatively safe).

Prasugrel has minimal interaction with
PPIs, hence considered to be better choice in patients who are on PPIs and
require coronary stents.

Sunday, November 23, 2014

Q: 60-year old patient presented with the compliant of shortness of breath. Patient has 60 pack-year history of smoking. Patient sodium is 140meq/l, potassium is 4meq/l, chloride is 94meq/l, and HCO3 is 36meq/l. Patient abg revealed pCO2 is 70 and pH is 7.31. What is the acid base disturbance. A) Metabolic acidosis B) Acute Respiratory acidosis C) Chronic Respiratory acidosis D) Mixed Metabolic and Respiratory acidosis

Answer:CRationale: Patient anion gap is 10 that rules out metabolic acidosis. For every 10 Torr change in CO2 change in ph is 0.3 for chronic and 0.8 for acute. Since the change in torr of CO2 in this case is 30, and ph is 7.31 that makes it chronic respiratory acidosis. If it would have been acute that the ph should have been 7.16 (0.08x3=0.24; 7.4-.24=7.16)

Saturday, November 22, 2014

Q; 30-year old patient with history of diabetes, presented to the hospital with c/o nausea and vomiting. Patient sodium was 140meq/l, potassium was 4meq/l, chloride was 105meq/l, HCO3 was 5meq/l. On ABG pCO2 was 16 and pH was 7.11. What is the acid base disturbance? A) Metabolic acidosis B) Respiratory acidosis C) Mixed metabolic and respiratory acidosis D) Triple acid-base disturbance

Friday, November 21, 2014

Q; Patient with history of hypertension and anxiety presented to the hospital with tachypnea. Patient sodium was 140meq/l, potassium was 3meq/l, chloride was 94meq/l and HCO3 was 34. On arterial blood gas, PH was 7.67 and pCO2 was 30. What is the acid base disturbance? A) Respiratory alkalosis B) Metabolic alkalosis C) Respiratory and metabolic alkalosis D) Hyperchloremic non-anion gap metabolic acidosis Answer: C Rationale: Patient HCO3 is high suggestive of metabolic alkalosis. Patient expected CO2 should be (pCO2=HCO3x0.9+9; 34x0.9+9=39.6); CO2 is 30, which is lower than expected pCO2, suggestive of mixed respiratory and metabolic alkalosis.

Thursday, November 20, 2014

Patient presented to ED with complaint of vomiting and was found to be hypotensive. Patient sodium was 140meq/l, potassium was 3meq/l, chloride was 92meq/l and HCO3 was 29. On arterial blood gas the patient ph was 7.61 and pCO2 was 30. What is the underlying acid-base disturbance? A) Mixed respiratory and metabolic alkalosis B) Mixed respiratory alkalosis and metabolic acidosis C) Respiratory alkalosis, metabolic acidosis and metabolic alkalosis D) Respiratory acidosis and Respiratory alkalosis Answer: C Rationale: Patient PH is high suggestive of alkalosis. Patient HCO3 is high suggestive of metabolic alkalosis, the PCO2 should be high to compensate, but it is low, suggestive of concurrent respiratory alkalosis. Patient anion gap is 19 suggestive of metabolic acidosis. Hence the picture is consistent with metabolic acidosis, metabolic alkalosis and respiratory alkalosis. Patient cannot have respiratory acidosis and respiratory alkalosis together, as one cannot breath slowly and fast at the same time.

Rationale: Patient has pH of 7.49 suggestive of alkalosis. pCO2 is within normal range excluding respiratory alkalosis. The pH is high and chloride is 93 meq/L showing no indication of hyperchoremic metabolic acidosis. HCO3 is high and expected pCO2is within normal range (Expected CO2=0.9 x HCO3+9; .9X35+9=40.5) suggestive of simple compensated metabolic alkalosis as seen with diuretic therapy.

Rationale: Patient ph is 7,45 making it alkalosis, and the bicarbonate is not high, whereas the pCO2 on arterial blood gas is low suugestive of respiratory alkalosis, as can be seen in the pregnant patient or in severe acute anxiety.

Monday, November 17, 2014

Q: 36 year old female,
who is now recouping from exacerbation of Asthma in ICU and just finished her
breakfast with large cup of coffee went into sustained SVT with heart rate of
240. You decided to administer Adenosine. What would be your
concern?

Answer:Patient may need higher doseTheophylline (which this patient may
have use for Asthma) and caffeine antagonize adenosine's effects, so standard
dose of 6 mg IV bolus may not work and an increased dose of adenosine may be
required. On the contrary, Dipyridamole potentiates the action of adenosine,
requiring the use of half of the standard dose.

Sunday, November 16, 2014

Q: How just eye balling pulse oximetry on monitor can help in diagnosis of patient having suspicion of cardiac tamponade?Answer: Patients with suspicion of cardiac tamponade, usually show increased respiratory variability in pulse-oximetry waveform.

Saturday, November 15, 2014

Q: How much water need to
be mixed to prepare one vial of Dantrium?

Answer: 60 cc

Each vial of Dantrium Intravenous should be
reconstituted by adding 60 mL of sterile water and the vial shaken until the
solution is clear. 5% Dextrose or 0.9% Sodium Chloride are not compatible with
Dantrium Intravenous.

Dantrium is used for the prophylaxis and treatment of
Malignant Hyperthermia (MH). The recommended prophylactic dose of Dantrium
Intravenous is 2.5 mg/kg, starting approximately 60-75 minutes before
anticipated anesthesia. It requires infusion over approximately 1
hour.

In post crisis intravenous Dantrium is
used to attenuate malignant hyperthermia. The i.v. dose of Dantrium in the
postoperative period starts with 1 mg/kg or more as the clinical situation
dictates.

Friday, November 14, 2014

Q: Which pericarditis does not usually presents with classic ST elevations on EKG

Answer: Uremic pericarditis

In Uremic Pericarditis, classic finding of diffuse ST elevations are rare; rather more commonly, non- specific repolarization changes are present. This is due to the relative lack of epicardial electrical injury. Also, pericardial fluid is enriched with oppositely charged uremic molecules which neutralizes the electrical gradient.

Monday, November 10, 2014

Q: Which one disease process need to be ruled out in severe pruritus associated with kidney failure, also known as Uremic pruritus?

Answer: Hyperparathyroidism

If despite symptomatic treatment and increasing the dose/frequency of dialysis - uremic pruritus is not resolving, other disease processes particularly hyperparathyroidism need to be ruled out. Data is almost 45 years old but still is clinically relevant.

Sunday, November 9, 2014

Q: 56 year old male with ESRD is admitted to ICU with VRE pneumonia and sepsis. Due to hemodynamic compromise, initially patient was put on CRRT. Patient responded well to Linezolid and is now switched to regular hemodialysis (HD). What care should be taken to maintain efficacy of Linezolid?

Answer: Administer linezolid after HD session.

HD removes 30–40% of a dose of Linezolid so it should be given after HD session on the day of dialysis. In CRRT no adjustment is needed but every 8 hours administration instead of every 12 hours of total daily dose is advisable.

Friday, November 7, 2014

Q: Can CPR be done in Prone position?

Answer:Yes.

Also known as reverse CPR, has actually shown to generates higher mean Systolic blood pressure and higher Mean Arterial Pressure during circulatory arrest than standard CPR. It can be done by turning the head to the side and compressing the back.

Wednesday, November 5, 2014

Q: 74 year old male with Parkinson's Disease is admitted to ICU with
Urosepsis. Patient is recovering well. A night before transfer to floor, patient
start displaying signs of delirium and psychosis. Which anti-psychotic would be
of use?

Answer:Quetiapine

Quetiapine and clozapine
are recommended for the treatment of Parkinson's disease related psychosis because
of their low extrapyramidal side effects. Clozapine is known for some heavy side
effects alike agranulocytosis, therefore quetiapine would be considered as a
better choice.

Monday, November 3, 2014

HbA1c is widely used as a marker of glycaemic control and has been proposed and used, but not yet officially accepted, as a diagnostic marker for diabetes. We have tested its usefulness for diagnosing diabetes in the intensive care setting.

Methods

All patients with negative history for DM and hyperglycaemia in ICU were called for measurement of fasting glucose and OGTT within 1 month after discharge.

Results

There were 618 patients in the cohort: 293 patients had hyperglycaemia during the ICU stay and no information about DM in the history. Cut-off of 6% had 97% sensitivity and 93% specificity for pre-diabetes, 7% cut-off had 95% sensitivity and 98% specificity for DM.

Conclusions

HbA1c can be used for diagnosing diabetes and pre-diabetes in patients with critical care hyperglycaemia with high sensitivity and specificity.

Reference:

I Gornik, A Vujaklija-Brajković and V Gašparović - Validation of HbA1c as a diagnostic marker for diabetes in the critically ill -Critical Care 2010, 14(Suppl 1):P581